Paediatric Intensive Research Articles

SARS-CoV-2, Lung Protective Ventilation, Low Middle Income Countries, and Pediatric Intensivists as Cross Disciplinary Knowledge Translation and Implementation Science Specialists

PurposeWe hypothesized that despite the low incidence of severe SARS-CoV-2 infections in children in Guyana, due to their specific skillset in lung protective ventilation, our Pediatric Intensivists were uniquely positioned to address significant training and readiness gaps in our colleagues attending a surging critically ill Adult COVID-19 patient population.Methods & MaterialsIn Guyana, there are few clinicians trained in Critical-Care Medicine (CCM). The high incidence of ventilator dependence in seriously ill SARS-CoV2 patients, combined with a dearth of CCM practitioners competent in complex mechanical ventilation management left Guyana ill prepared to manage these patients. This knowledge deficit was further exacerbated in that many clinicians at our National Infectious Diseases Hospital were co-opted into CCM roles from other specialties with little to no CCM training. We have a very small core of Pediatric Surgical Critical Care Medicine staff that was formally trained in PCCM outside of Guyana. This core was instrumental in establishing a unique and formal Pediatric Critical-Care Medicine Micro-Modular Fellowship (PCCM-MMF) program that allowed the creation of Guyana's only Pediatric ICU. A significant number of that core are also involved in Guyana‘s National COVID Task Force. Given that all graduates of our PCCM-MMF program are extensively trained in Lung Protective Ventilation, it was very appropriate to utilize them to augment Adult critical care capacity. Thirty physicians with primarily adult practices and little to no previous knowledge of ventilator management were enrolled in a multi-modal triphasic mechanical ventilation short course facilitated by PCCM staff.ResultsWe were able to rapidly enable two cohorts of 15 Adult clinicians to competently address critical knowledge deficits and staffing shortfalls. We improved morbidity and mortality amongst our mechanically ventilated adult COVID-19 patients, as well as relieved significant multifactorial caregiver strain.ConclusionOur successful utilization of PCCM staff as Mechanical Ventilation didactic and clinical educators for an Adult patient population carries implications for cross disciplinary Knowledge Translation and Implementation Science in a wide variety of practice milieus. We are actively pursuing research opportunities to further experiment with other skill sets incorporated in our PCCM Micro-Modular Fellowship and welcome potential collaborators.

Multisystem inflammatory syndrome and COVID-19: a scoping review.

Multisystem inflammatory syndrome temporally associated with COVID-19 presents with similar symptomatology and therapeutic approach to Kawasaki disease in the pediatric population. Given the novelty of the disease and the growing scientific literature on the subject, it is relevant to collect and report available scientific information. This review aimed to explore the medical evidence on multisystem inflammatory syndrome temporally associated with COVID-19 in a population under 18 years of age. We conducted a scoping review using Scopus and PubMed, including observational (cohort, case-control, and cross-sectional) studies and case series. Of the total articles reviewed as of April 10, 2021, 45 articles met eligibility criteria: case series (n = 32), retrospective cohort studies (n = 6), prospective cohort studies (n = 4), case-control studies (n = 2), and cross-sectional studies (n = 1). Gastrointestinal and respiratory symptoms and myocardial dysfunction are the most commonly reported. The most relevant paraclinical markers were lymphopenia, thrombocytopenia, and elevated D-dimer levels. The multisystem inflammatory syndrome temporally associated with COVID-19 presents a broad spectrum of signs and symptoms. Aneurysms of the coronary arteries and myocarditis are usually present in the acute phases of the disease. The early diagnosis led by a multidisciplinary group of pediatric intensivists, infectious disease specialists, cardiologists, and rheumatologists allows adequate and effective medical management.

The Decision to Extubate: The Association between Clinician Impressions and Objective Extubation Readiness Criteria in a Pediatric Intensive Care Unit

Abstract Objective Objective tools such as spontaneous breathing trials (SBT) aim to identify patients ready for extubation and shorten the length of mechanical ventilation (MV). Despite passing an SBT, patients sometimes are not extubated based on clinicians' subjective impressions. In this article, we explored the factors that influence the decision to extubate among pediatric intensivists and their association with objective criteria. Design This is a single-center prospective observational study. Setting This study was conducted in an academic, multidisciplinary 20-bed pediatric intensive care unit (PICU). Patients The study group involves mechanically ventilated, orally intubated patients admitted to the PICU from January 1 to June 30, 2019. Measurements and Main Results Objective clinical data were collected for 650 MV days. Attending surveys about extubation readiness were completed for 419 (64.5%) MV days and 63 extubation events. Extubation occurred on 42% of days after passing an SBT. The primary reasons patients who passed an SBT were not extubated on days were unresolved lung pathology (66.6%) and fluid overload (37.6%). On days without extubation, there was no association between a specific reason for not extubating and SBT result (p > 0.05). Conclusions In this single-center study, the decision to extubate was not strongly associated with passing an SBT, indicating that clinician impressions, namely unresolved lung pathology and fluid overload, outweighed objective measures for determining extubation readiness. To mitigate morbidities and costs associated with unnecessarily prolonged intubations, a better-defined extubation readiness process is needed to guide the decision to extubate in the pediatric population.

Same baby, different care: variations in practice between neonatologists and pediatric intensivists.

Our study identified major differences in respiratory and hemodynamic care, sedation and analgesia, and vascular access between NICU and PICU physicians, resulting from field-specific consensus guidelines and practice traditions. We suggest to establish joint committees from both professions, aimed at finding the optimal treatment for this vulnerable population - be it in the NICU or in the PICU. • Variability in neonatal care between the neonatal and the pediatric intensive care units has been previously described. • This scenario-based survey study identified major differences in respiratory and hemodynamic care, sedation and analgesia, and vascular access between neonatologists and pediatric intensivists, resulting from lack of evidence-based literature to guide neonatal care, field-specific consensus guidelines, and practice traditions. • These findings indicate a need for joint committees, combining the unique skills and literature from both professions, to conduct clinical trials focusing on these specific areas of care, aimed at finding the optimal treatment for this vulnerable population - be it in the neonatal or the pediatric intensive care unit.

Validity and Reliability of the Richmond Agitation-Sedation Scale in Pediatric Intensive Care Patients: A Multicenter Study.

Background: There is limited data about the psychometric properties of the Richmond Agitation-Sedation Scale (RASS) in children. This study aims to analyze the validity and reliability of the RASS in assessing sedation and agitation in critically ill children.Methods: A multicenter prospective study in children admitted to pediatric intensive care, aged between 1 month and 18 years. Twenty-eight observers from 14 PICUs (pediatric intensive care units) participated. Every observation was assessed by 4 observers: 2 nurses and 2 pediatric intensivists. We analyzed RASS inter-rater reliability, construct validity by comparing RASS to the COMFORT behavior (COMFORT-B) scale and the numeric rating scale (NRS), and by its ability to distinguish between levels of sedation, and responsiveness to changes in sedative dose levels.Results: 139 episodes in 55 patients were analyzed, with a median age 3.6 years (interquartile range 0.7–7.8). Inter-rater reliability was excellent, weighted kappa (κw) 0.946 (95% CI, 0.93–0.96; p < 0.001). RASS correlation with COMFORT-B scale, rho = 0.935 (p < 0.001) and NRS, rho = 0.958 (p < 0.001) was excellent. The RASS scores were significantly different (p < 0.001) for the 3 sedation categories (over-sedation, optimum and under-sedation) of the COMFORT-B scale, with a good agreement between both scales, κw 0.827 (95% CI, 0.789–0.865; p < 0.001), κ 0.762 (95% CI, 0.713–0.811, p < 0.001). A significant change in RASS scores (p < 0.001) was recorded with the variance of sedative doses.Conclusions: The RASS showed good measurement properties in PICU, in terms of inter-rater reliability, construct validity, and responsiveness. These properties, including its ability to categorize the patients into deep sedation, moderate-light sedation, and agitation, makes the RASS a useful instrument for monitoring sedation in PICU.

Closed-PICU perioperative management of congenital tracheal stenosis.

Perioperative management of congenital tracheal stenosis (CTS) is challenging. In the present study, compared the effect of closed-pediatric intensive care unit (PICU) perioperative management by pediatric intensivists and open-PICU management by surgeons. Outcomes in terms of ventilator-free days (VFD) and length of postoperative PICU stay in children with CTS were evaluated. This retrospective cohort study was conducted in a PICU in Japan. Children with CTS who underwent slide tracheoplasty were grouped according to whether they were perioperatively managed in an open (January 2015 to April 2016) or a closed (May 2016 to August 2019) PICU. Data were extracted from patients' medical records. In total, 13 and 38 patients were included in the open- and closed-PICU groups, respectively. Compared to the open-PICU group, the closed-PICU group had shorter duration of muscle relaxant administration (median 4 vs 5 days; P < 0.001), earlier enteral nutrition (34/38 [90%] vs 1/13 [8%]; P < 0.001), more 28-day VFD (median 21 vs 20 days; P = 0.04), and shorter duration of postoperative PICU stay (median 16 vs 36 days; P = 0.002), but mortality did not differ significantly between the two groups (0/38 [0%] vs 1/13 [8%]; P = 0.25). Closed-PICU perioperative management with pediatric intensivists' participation significantly increased 28-day VFD and reduced the length of postoperative PICU stay in patients with congenital tracheal stenosis.

Awareness and management of intra-abdominal hypertension and abdominal compartment syndrome by paediatric intensive care physicians: anational survey.

This study aimed to evaluate the current awareness and management of intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) among paediatric intensivists. Aweb-based electronic survey was sent to all physicians working in paedia-tric intensive care units (PICUs) in Saudi Arabia. The survey questions obtained information regarding awareness of ACS and IAH, recognition criteria, monitoring of intra-abdominal pressure (IAP), and experience in managing ACS. Atotal of 79 physicians responded to the survey (response rate: 53%). Among respondents 48% were consultants. 85% of respondents were familiar with IAP/IAH/ACS. Only 35% and 10% were aware of the Abdominal Compartment Society consensus definitions for IAH and ACS in the paediatric population, respectively. Most respondents considered the cut-off for IAH to be ≥ 15 mm Hg, and approximately two-thirds thought that the cut-off for ACS was higher than the currently suggested consensus definition (10 mm Hg). More than two-thirds of respondents monitored IAP in the PICU, and it was measured almost exclusively via the bladder (96%); the majority (70%) reported that they instilled volumes well above the current recommendations. Medical management was the most frequent therapeutic approach to treat IAH/ACS, while surgical decompression was the least attempted option. Decisions to decompress the abdomen were predominantly based on the presence of organ dysfunction (74.4%). This survey showed that although most responding physicians claim to be familiar with IAH and ACS, their knowledge of published consensus definitions, measurement techniques, and clinical management must be updated.

A Fatal Case of Febrile Ulceronecrotic Mucha-Habermann Disease in a 10-Year-Old Boy.

A Fatal Case of Febrile Ulceronecrotic Mucha-Habermann Disease in a 10-Year-Old Boy.

Executive Summary of Recommendations and Expert Consensus for Plasma and Platelet Transfusion Practice in Critically Ill Children: From the Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding (TAXI-CAB).

Critically ill children frequently receive plasma and platelet transfusions. We sought to determine evidence-based recommendations, and when evidence was insufficient, we developed expert-based consensus statements about decision-making for plasma and platelet transfusions in critically ill pediatric patients. Systematic review and consensus conference series involving multidisciplinary international experts in hemostasis, and plasma/platelet transfusion in critically ill infants and children (Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding [TAXI-CAB]). Not applicable. Children admitted to a PICU at risk of bleeding and receipt of plasma and/or platelet transfusions. None. A panel of 29 experts in methodology, transfusion, and implementation science from five countries and nine pediatric subspecialties completed a systematic review and participated in a virtual consensus conference series to develop recommendations. The search included MEDLINE, EMBASE, and Cochrane Library databases, from inception to December 2020, using a combination of subject heading terms and text words for concepts of plasma and platelet transfusion in critically ill children. Four graded recommendations and 49 consensus expert statements were developed using modified Research and Development/UCLA and Grading of Recommendations, Assessment, Development, and Evaluation methodology. We focused on eight subpopulations of critical illness (1, severe trauma, intracranial hemorrhage, or traumatic brain injury; 2, cardiopulmonary bypass surgery; 3, extracorporeal membrane oxygenation; 4, oncologic diagnosis or hematopoietic stem cell transplantation; 5, acute liver failure or liver transplantation; 6, noncardiac surgery; 7, invasive procedures outside the operating room; 8, sepsis and/or disseminated intravascular coagulation) as well as laboratory assays and selection/processing of plasma and platelet components. In total, we came to consensus on four recommendations, five good practice statements, and 44 consensus-based statements. These results were further developed into consensus-based clinical decision trees for plasma and platelet transfusion in critically ill pediatric patients. The TAXI-CAB program provides expert-based consensus for pediatric intensivists for the administration of plasma and/or platelet transfusions in critically ill pediatric patients. There is a pressing need for primary research to provide more evidence to guide practitioners.

Perceived barriers to effective enteral and parenteral nutrition in pediatric intensive care units in Ecuador: a multicenter survey study.

Aims: To identify the main barriers perceived by pediatric intensive care healthcare professionals in delivering enteral and parenteral nutrition to critically ill children in Ecuador. Methods: An online cross-sectional survey was sent electronically from May 2020 to July 2020 to PICU intensivists, pediatricians, nurses, and dieticians across Ecuador. The questionnaire consisted of 27 questions on the barriers to enteral nutrition (EN) and 10 questions on the barriers to parenteral nutrition (PN). Respondents were asked to rate each barrier based on a 7-point Likert scale that ranged from 0 = “it is not a barrier at all” to 6 = “it has a great influence as a barrier”. Each barrier was classified into three categories according to the Likert scale score: no barrier (0), moderate barrier (1-3), and important barrier (4-6). Results: A total of 119 responses from 16 hospitals were obtained. 34% of respondents were pediatricians, 21% pediatric intensivists, 39% nurses, and 6% dieticians. The top 5 perceived barriers for EN were: 1) Feeding being held too far in advance of procedures or operating room visits, 2) Not enough time dedicated to education and training, 3) No or not enough dietician coverage during evenings, weekends, and holidays 4) Dietician not routinely present on weekday patient rounds, 5) Lack of familiarity with current guidelines for nutrition. For PN the top three perceived barriers were: 1) Waiting for physician to place a central venous catheter and then request and review X-ray to confirm its correct placement, 2) There is no PN protocol in place or it is not applied, 3) There is no catheter or catheter lumen available for PN purposes only. Conclusions: Our study shows that many perceived barriers to EN in Ecuadorian PICUs are like those found internationally. Barriers to the implementation of PN were also evaluated, finding organizational problems to be one of the main limitations. Most of the identified barriers can be overcome through practical strategies such as the development of specific protocols for enteral and parenteral nutrition and the conformation of multidisciplinary teams. It is essential to implement continuous training programs in nutrition for all health personnel in charge of critically ill pediatric patients.

The Impact of a Pediatric Continuity Care Intensivist Program on Patient and Parent Outcomes: An Unblinded Randomized Controlled Trial.

Objectives We studied the impact of a standardized continuity care intensivists (CCIs) program on patient and family outcomes for long-stay patients in the pediatric intensive care unit (PICU), also assessing the intervention's acceptability and feasibility. Methods A patient-level, unblinded randomized-controlled trial in a PICU at a large children's hospital. Participants included: (1) patients with ≥ 7 days PICU admission and likely to stay another 7 days; (2) their parents; (3) PICU attendings participating as continuity attendings; and (4) PICU attendings providing usual care (UC). We examined a bundled intervention: (1) standardized continuity attending role, (2) communication training course for CCI, and (3) standardized timing of contact between CCI and patient/family. Results Primary outcome was patient PICU length of stay. Secondary outcomes included patient, parental, and clinician outcomes. We enrolled 115 parent-patient dyads (231 subjects), 58 patients were randomized into treatment arm and 56 into the UC arm. Thirteen attendings volunteered to serve as CCI, 10 as UC. No association was found between the intervention and patient PICU length of stay ( p = 0.5), other clinical factors, or parental outcomes. The intervention met a threshold for feasibility of enrollment, retention, and implementation while the majority of providers agreed the intervention was acceptable with more efficient decision making. Thirty percent CCIs felt the role took too much time, and 20% felt time was not worth the benefits. Conclusion CCI intervention did not impact patient or family outcomes. PICU attendings believed that the implementation of the CCI program was feasible and acceptable with potential benefits for efficiency of decision making.

Ontogeny of Pediatric Pharmacogenetics: Celebrating the Past and Vision for the Future.

Ontogeny of Pediatric Pharmacogenetics: Celebrating the Past and Vision for the Future.

Noninvasive ventilation in children: A review for the pediatric anesthesiologist.

Preserving adequate respiratory function is essential in the perioperative period. Mechanical ventilation with endotracheal intubation is widely used for this purpose. In select patients, noninvasive ventilation (NIV) may be an alternative to invasive ventilation or may complement respiratory management. NIV is used to provide ventilatory support and increase gas exchange at the alveolar level without the use of an invasive artificial airway such as an endotracheal tube or tracheostomy. NIV includes both continuous positive airway pressure (CPAP) and noninvasive positive pressure ventilation. Indications for NIV range from acute hypoxic respiratory failure in the intensive care unit or the emergency department, to chronic respiratory failure in patients with neuromuscular disease with nocturnal hypoventilation. In the perioperative setting, NIV is commonly applied as CPAP, and bilevel positive airway pressure (BPAP). There are limited data on the role of NIV in children in the perioperative setting, and there are no clear guidelines regarding optimal timing of use and pressure settings of perioperative NIV. Contraindications to the use of NIV include reduced level of consciousness, apnea, severe respiratory distress, and inability to maintain upper airway patency or airway protective reflexes. Common problems encountered during NIV involve airway leaks and asynchrony with auto-triggering. High-flow nasal oxygen (HFNO) has emerged as an alternative to NIV when trying to decrease the work of breathing and improve oxygenation in children. HFNO delivers humidified and heated oxygen at rates between 2 and 70L/min using specific nasal cannulas, and flows are determined by the patient's weight and clinical needs. HFNO can be useful as a method for preoxygenation in infants and children by prolonging apnea time before desaturation, yet in children with decreased minute ventilation or apnea HFNO does not improve alveolar gas exchange. Clinicians experienced with these devices, such as pediatric intensivists and pulmonary medicine specialists, can be useful resources for the pediatric anesthesiologist caring for complex patients on NIV.

Preschool Confusion Assessment Method for the Intensive Care Unit–Spanish (psCAM-ICU-S): Cross-Cultural Adaptation and Validation in Colombia

Objective: The goal of the present study was to perform a cross-cultural adaptation and clinical validation of the Preschool Confusion Assessment Method for the Intensive Care Unit–Spanish (psCAM-ICU-S) for its clinical use in the Colombian Population.Methods: We designed a Cross-cultural adaptation study followed by a cross-sectional validation study at a Single-center Pediatric Intensive Care Unit (PICU) at a University Hospital in Bogotá, Colombia. The study population was children aged from 6 months to 5 years and 11 months who had been treated in the PICU with a Richmond sedation-agitation scale score of−3 or higher. A three-phase study was carried out. The first phase comprised the application of psychometric tests on the tool. In the second phase, the psCAM-ICU-S was applied to the target population. Patients were evaluated by a nurse and a pediatric intensivist using the psCAM-ICU-S; additionally, a child psychiatrist evaluated each patient using the DSM-V criteria; the psychiatrist evaluation was chosen as the gold standard for the diagnosis of delirium. In the third phase, an evaluation of the tool's effectiveness was carried out by using sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and likelihood ratios. Interrater agreement was also assessed by using the Fleiss' kappa.Results: Psychometric tests established the instrument's reliability and consistency as well as the clarity of its items. A total of 31 patients were evaluated. On average, the instrument presented a sensitivity of 93.3%, specificity of 94.8%, PPV 78%, NPV 99%, a positive likelihood ratio of 19.93, and a negative ratio of 0.07. The prevalence of delirium was 16.1% by the child psychiatrist and 25.8% using de psCAM-ICU-S. We confirmed high Interrater agreement, Kappa index (0.672–0.902).Conclusions: The psCAM-ICU-S was a valid and reliable instrument for the diagnosis of delirium in critically ill pediatric patients.

Antibiotic Stewardship Practices and Prescribing Patterns Across Indian PICUs.

To elicit antibiotic prescribing patterns across Indian Pediatric Intensive Care Units (PICU) and assess attributes of the antibiotic stewardship programs. A link to a web-based questionnaire was sent by email to pediatric intensivists across India. Responses were received from 62 PICUs. Majority of respondents were from private hospitals [49/62 (79.5%)]. The most commonly reported infection requiring PICU admission was community-acquired pneumonia [by 39 (62.9%) PICUs] followed by gastroenteritis [26 (41.9%)], and meningitis [15 (24.1%)]. The blood culture positivity rates varied among participating PICUs with 37 centers (59.6%) reporting low blood culture positivity yield (< 40%). Majority of the respondents acknowledged using a 7-d course of antibiotics even in culture-negative sepsis. Most common empiric antibiotics prescribed for community-acquired infections were beta-lactam monotherapy. The typical beta-lactam prescribed was ceftriaxone. However, for hospital-acquired infections (HAI), such as suspected catheter-related bloodstream infection (CLABSI) and suspected ventilator-associated pneumonia (VAP), a higher number of respondents-39/62 (61.9%) and 33/62 (53.2%), respectively, prescribed combination antibiotics (β-lactam + vancomycin). Forty-two units (67.7%) reported having an antibiotic stewardship program in their PICUs, while twenty-nine (45.1%) centers stated having formulary restrictions. Ten (16.1%) centers had pre-authorization policy for certain antibiotics. A rather diverse pattern of prescribing and administration practices exists across different Indian PICUs. While antibiotic stewardship programmes are established in most centers, formulary restriction and pre-authorisation of antibiotic prescribing were reported by few units. Regular surveillance studies are needed to bring uniformity in antibiotic policy and select appropriate empiric therapy.

Asthma Control and Psychological Health in Pediatric Severe Asthma

To determine the prevalence of anxiety and depression and impact on asthma control in pediatric patients with severe asthma.Children aged ≥4 years who were referred to the Boston Children’s Hospital Severe Asthma Program by a pediatric pulmonologist, allergist, or intensivist after a life-threatening asthma exacerbation.This was a single-center prospective cohort study from March 2017 to December 2019. Asthma severity for each participant was defined on the basis of the National Heart, Lung, and Blood Institute (NHLBI) asthma medication steps. At each clinical encounter, children completed the Patient Health Questionnaire (PHQ-4) and the Asthma Control Test (ACT) or childhood ACT with parental assistance and had spirometry done to assess lung function, including forced expiratory volume in 1 second (FEV1) to forced vital capacity. The association of the longitudinal psychological assessments and pulmonary function measures were determined by using a linear mixed model (adjusted for sex, age, race, and NHLBI asthma medication step).Data were obtained for 93 clinical encounters from 43 patients. The mean age was 11.7 (+/− 4.2) years; 65% were male (n = 28 of 43); 49% were White (n = 22 of 43). The median NHLBI asthma medication step was 5.5 (interquartile range: 4.5–6.0). A total of 58% (n = 25 of 43) had at least 1 symptom of anxiety and depression, and 19% (n = 8 of 43) had a PHQ-4 score >2, indicating at least mild impairment. Bivariate analyses after adjusting for age, sex, race, and medication step revealed a significant difference in mean ACT scores (7 points lower) for girls with a PHQ-4 score >2 versus that of those with a score ≤2 (95% confidence interval [CI]: −10.88 to −3.12; P = .01); this effect was not seen in mean ACT scores for boys with PHQ-4 scores >2 versus that of those with scores ≤2. Compared with girls, boys with PHQ-4 scores >2 had a mean ACT score that was 4.18 points higher (95% CI: 0.63 to 7.73; P = .03). A PHQ-4 score >2 was significantly associated with percent FEV1 predicted but not with FEV1 to forced vital capacity (95% CI: −33.83 to 1.12; P = .06).Pediatric patients with severe asthma often have comorbid mental health impairment, which is associated with poor asthma-related quality of life. Girls with greater anxiety and depression perceived significantly worse asthma control. No difference in perceived asthma control was seen in boys, regardless of anxiety or depression level.Individuals with poorly controlled asthma can have psychological comorbidities including anxiety and depression, whereas, conversely, these factors can exacerbate asthma and negatively impact asthma control and severity. The perception of asthma control may impact self-care, asthma self-management, and inaccurate perception of symptoms, potentially resulting in higher rates of asthma-related health care use. Just as women often are more likely to report symptoms than men, the girls in this study had the higher level of mental health impairment and more negatively perceived asthma control. Although sex differences were observed in the association between psychological impairment and perceived asthma control, there was no association with objective spirometry results. Study limitations include the small sample size and use of PHQ-4, which is not a standard psychological screening tool. However, with these results, the authors highlight the potential impact of psychological symptoms in our clinical management of patients with asthma.

PICU Follow-Up Clinic: Patient and Family Outcomes 2 Months After Discharge.

Hospitalization in a PICU is a life-altering experience for children and their families. Yet, little is known about the well-being of these children after their discharge. We are describing the outcome of PICU survivors at a PICU clinic 2 months after discharge. Prospective cohort study. PICU and PICU clinic of CHU Sainte-Justine. Prospective cohort study of children admitted for greater than or equal to 4 days, greater than or equal to 2 days of invasive ventilation, odds ratio greater than or equal to 4 days of noninvasive ventilation at Centre Hospitalier Universitaire Sainte-Justine. Prospective cohort study of children admitted for greater than or equal to 4 days, greater than or equal to 2 days of invasive ventilation, or greater than or equal to 4 days of noninvasive ventilation at Centre Hospitalier Universitaire Sainte-Justine PICU. None. Patients were evaluated by a pediatric intensivist 2 months after discharge at the follow-up clinic. They were asked to fill out validated questionnaires. One hundred thirty-two patients were followed from October 2018 to September 2020. The PICU diagnoses were respiratory illness (40.9%), head trauma, and septic shock (7.6%). Average length of PICU stay was 28.5 ± 84.2 days (median 7 d). Sixty-one percent were intubated. Symptoms reported by families were as follows: fatigue (9.9%), sleep disturbances (20.5%), feeding difficulties (12.1%), and voice change and/or stridor (9.8%). Twenty-one percent of school-aged children reported school delays. Twenty-seven children demonstrated communication delays, 45% gross motor function delays, 41% fine motor delays, 37% delays in problem-solving, and 49% delays in personal-social functioning. Quality of Life scores were 78.1 ± 20.5 and 80.0 ± 17.5 for physical and psychosocial aspects, respectively. Fourteen percent of parents reported financial difficulties, 42% reported symptoms of anxiety, 29% symptoms of depression. PICU survivors and their families experience significant physical and psychosocial morbidities after their critical illness. PICU follow-up is crucial to determine the outcome of these children and develop interventions.

2021 PACES Expert Consensus Statement on the Indications and Management of Cardiovascular Implantable Electronic Devices in Pediatric Patients: Executive Summary.

2021 PACES Expert Consensus Statement on the Indications and Management of Cardiovascular Implantable Electronic Devices in Pediatric Patients: Executive Summary.

The impact of socioeconomic status and race on the outcomes of congenital heart disease.

Studying the outcomes of congenital heart disease and their associations allows paediatric cardiologists and intensivists to improve the care and health equity of their patients. This review presents the most recent literature discussing the socioeconomic and racial disparities that pervade the outcomes of patients with congenital heart disease in every facet of treatment. The outcomes of congenital heart disease discussed are prenatal detection, maintenance of care, quality of life, neurodevelopment and mortality. Historically, it has been documented that patients with congenital heart disease who are of racial and ethnic minorities disproportionately experience poor outcomes. Recently, the association between racial minorities and mortality has been traced to underlying socioeconomic disparities emphasizing that race and ethnicity are not independent determinants of health. The effect of socioeconomic status on the outcomes of congenital heart disease is profound and reaches beyond the association with racial and ethnic minorities. Changes to address these disparities in outcomes must be made at the individual, institutional, community and system levels.

Manajemen Low Flow Anesthesia pada Pasien Kraniosinostosis dengan Hipertelorisme yang menjalani Four Box Wall Osteotomy, dan Eksisi Redundant Skin Fronto Nasal

Craniosynostosis is a case that diagnosed in the first year of life and can need surgical in young age. Craniosynostosis is a part of hypertelorism with incidence rate around 20%. Boy, 13 years old with hypertelorism had undergone multiple surgery for correction of hypertelorism before. Patient was planned to advance surgical correction of four box wall osteotomy which consist frontal part correction and part of it is release craniosynostosis in coronal suture. Risk of massive bleeding because patient already in teen age and length of surgery can be prolonged. Difficult airway management due to fascial deformity, use of low flow anesthesia to preserve temperature and reduce inhalation anesthesia usage, intraoperative fluid management in consideration maintenance and replacement blood loss and post operative pain management has become another consideration. Covid-19 as part of problems post operatively being known before extubation made the process is delayed. Massive bleeding needs massive transfusion protocol to speed up blood availability. Blood product such as PRC, FFP and TC should be available because coagulation factor is part of consideration. Anesthesia management in hypertelorism with four box wall osteotomy need good communication between anesthesiologist, neurosurgeon, plastic surgeon and pediatric intensivist to reduce perioperative risk including covid-19 in pandemic era.